HESI LPN
HESI Fundamentals 2023 Test Bank
1. A client needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?
- A. Cheddar cheese
- B. White rice
- C. Apples
- D. Green beans
Correct answer: A
Rationale: Cheddar cheese is the correct answer as it is a good source of complete protein that contains all essential amino acids required for maintaining a positive nitrogen balance for wound healing. Complete proteins provide all essential amino acids needed by the body. White rice, apples, and green beans do not offer complete proteins like cheddar cheese, making them inadequate choices for this purpose.
2. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
- A. Activate the emergency fire alarm
- B. Extinguish the fire
- C. Evacuate the client
- D. Confine the fire
Correct answer: C
Rationale: The correct action for the nurse to take next, after confirming the fire, is to evacuate the client. In a fire situation, following the RACE mnemonic, the priority is to rescue or evacuate clients to ensure their safety. Activating the emergency fire alarm (Choice A) is important to alert others and the fire department, but evacuating the client takes precedence. Extinguishing the fire (Choice B) may put the nurse and client at risk and is best left to trained personnel. Confining the fire (Choice D) is not the nurse's responsibility; the focus should be on ensuring the client's safety by evacuating them.
3. The healthcare provider is reviewing the plan of care for a client with a newly placed colostomy. Which outcome would indicate effective client teaching?
- A. Client demonstrates how to irrigate the colostomy.
- B. Client verbalizes understanding of dietary changes.
- C. Client performs ostomy care independently.
- D. Client expresses feelings about the impact of the colostomy.
Correct answer: C
Rationale: The correct answer is C because effective teaching is demonstrated when the client can independently perform ostomy care. This indicates that the client has understood and retained the information provided during teaching. Choices A, B, and D are incorrect because demonstrating how to irrigate the colostomy, verbalizing understanding of dietary changes, and expressing feelings about the impact of the colostomy are important aspects of care but do not directly reflect the client's ability to apply the taught information in a practical setting.
4. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
- A. Protective environment
- B. Airborne precautions
- C. Droplet precautions
- D. Contact precautions
Correct answer: D
Rationale: The correct answer is D: Contact precautions. When a client has an abdominal wound with purulent drainage, contact precautions are necessary to prevent the spread of infection through direct contact. Protective environment precautions are used for immunocompromised clients, airborne precautions are for diseases transmitted by airborne particles, and droplet precautions are for diseases transmitted by respiratory droplets. In this case, the focus is on preventing direct contact transmission, making contact precautions the most appropriate choice. Protective environment, airborne, and droplet precautions are not indicated in this scenario because the primary concern is the direct contact transmission of pathogens through the wound drainage.
5. A client is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?
- A. Drink a cup of hot cocoa before bedtime
- B. Exercise 1 hour before going to bed
- C. Use progressive relaxation techniques at bedtime
- D. Reflect on the day's activities before going to bed
Correct answer: C
Rationale: The correct answer is to recommend the client to use progressive relaxation techniques at bedtime. Progressive relaxation techniques help reduce stress and muscle tension, which can promote better sleep. Choice A, drinking a cup of hot cocoa before bedtime, contains caffeine which can interfere with falling asleep. Choice B, exercising 1 hour before going to bed, can stimulate the body and mind, making it harder to fall asleep. Choice D, reflecting on the day's activities before going to bed, may lead to increased mental activity and prevent relaxation, making it difficult to fall asleep.
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